Vascular Heart Diseases

mitral stenosis cause

rheumatic heart disease (from RF from group a b-hemolytic strep)

congenital - Lutembacher’s syndrome

mitral annular calcification

carcinoid tumours metastasizing to lung

echo pattern mitral stenosis

doming pattern (from reduction mitral valve orifice, inflammation → commissural fusion)

pathophysio mitral stenosis

orifice reduced → l atrial hypertrophy + dilation, increased bp, pul edema, pul htn → r ventricular hypertrophy → tricuspid regurgitation

symptoms mitral stenosis

asymptomatic until severe dyspnea, right heart failure (weak, fatigue, lower limb swell), risk Afib → emboli

signs mitral stenosis

mitral face - cyanotic or pink cheeks

small v. pulse that becomes irregular (afib)

jvd

tapping impulse on parasternal palpation on left

opening snap on auscultation, Graham steel murmur (pul valvular regurgitation from htn)

chest xray findings of mitral stenosis

left atrial enlargement, double shadow on border of r and l atria

late stage - calcified valve, enlarged main pul. a.

ecg mitral stenosis

bifid p wave

severe - afib, rvh

management early mitral stenosis

diuretics for dyspnea

b blockers or cardioversion for afib

management late mitral stenosis w/ symptoms/pul htn

• trans-septal balloon valvotomy

• closed valvotomy - for mobile, non calcified and non regurgitant mitral valves

• open valvotomy - + cardiopul bypass needed

• mitral valve replacement - for mitral regurg too, calcified valve, thrombus in l atrium

Lutembacher’s syndrome

congenital mitral stenosis and atrial septal defect

cause of mitral regurgitation

degenerative (myxomatous) disease, ischemic heart disease, rheumatic heart disease, infectious endocarditis, myocardial disease (lupus)

pathophysio mitral regurgitation

pulmonary edema, l ventricular hypertrophy

symptoms mitral regurgitation

dyspnea + orthopnea - from pul htn + lvf

fatigue + lethargy - from reduced CO

late stage - rhf

cardiac cachexia

subacute infective endocarditis

signs mitral regurgitation

lat displaced appex beat + systolic thrill

pansystolic murmur

midsystolic click

soft s1, prominent s3

chest xray results mitral regurgitation

left heart enlargement

ecg results mitral regurgitation

features of left atrial delay + ventricular hypertrophy - bifid p waves, tall R waves in l lat leads, deep S waves in r precordial leads

echo results mitral regurgitation

dilated l heart, chordal/papillary m rupture

management mitral regurgitation

follow up with echos - surgery if symptomatic severe or asymptomatic severe w/ preserved l ventricular fxn + afib

• diuretics, ace i, anticoags, mitraclip (repair)

Barlow’s syndrome (prolapsing mitral valve)

big mitral valve leaflets + annulus + long chordae or disordered papillary m contraction

myxomatous degeneration of leaflets on histo

calcific aortic valvular disease (CAVD)

inflammation subendothelium + fibrosis, calcification

risk factors of ___ are old men, elevated lipoprotein a + ldl, htn

cavd

bicuspid aortic valve

congenital heart disease, associated w/ aortic coarctation, root dilation + aortic dissection

which valves are affected in rheumatic heart disease

aortic + mitral stenosis

pathophysio aortic stenosis

increased l ventricular p + lvh, ischemia left ventricular myocardium → angina, arrythmias, lvf (worse w/ exercise)

symptoms aortic stenosis

asymptomatic until severe - exercise-induced syncope, angina, dyspnea

signs aortic stenosis

pulse is plateau + small volume

double impulse precordial palpation

ejection systolic murmur - diamond shaped

• systolic ejection click, reverse split on s2, prominent s4

results aortic stenosis on chest x-ray

small heart + dilated asc aorta (from post stenotic dilation)

aortic stenosis ecg

left ventricular strain pattern from pressure overload (depressed st, t-wave inversion in leads towards l ventricle)

echo aortic stenosis

thick calcified + immobile aortic valve, left ventricular hypertrophy

management aortic stenosis

aortic valve replacement - surgical, if symptomatic or asymptomatic + bad exercise test, low LVEF

• preemptive valvotomy

percutaneous valve replacement - indication in aortic stenosis

for aortic stenosis patients unsuitable for valve replacement

aortic regurgitation occur in which diseases

endocarditis (of aortic valve), marfan (of aortic root)

pathophysio aortic regurgitation

diastolic bp + coronary perfusion decreased, cardiac ischemia

symptoms aortic regurgitation

asymptomatic until left ventricular failure → angina, dyspnea

signs aortic regurgitation

collapsing pulse

Quincke’s sign - cap pulsations in nail bed

de Musset’s sign - head nodding w/ beat

Duroziez’s sign - to-fro murmur @ femoral a auscultation

pistol shot femorals - sharp bang over femoral a

apex beat displaced lat + down

high-pitched early diastolic murmur, Austin flint mid-diastolic murmur

how is murmur of aortic regurgitation best heard

left sternal edge in 4th intercostal space w/ patient leaning forwards and breath held in expiration

chest xray features of aortic regurgitation

left ventricular enlargement, dilation asc aorta (+ calcified if syphilis)

ecg aortic regurgitation

of left ventricular hypertrophy - tall R waves, deeply inverted T waves in left-sided leads, deep S waves in right-sided leads

echo aortic regurgitation

vigorous cardiac contraction, dilated left ventricle

diastolic fluttering of mitral leaflets or septum occurs in ______, producing the _______ murmur

aortic regurgitation

austin flint

management aortic regurgitation

vasodilators, inotropes, ace i if left ventricular dysfxn, b blockers in marfan

aortic surgery - if acute severe (endocarditis), symptomatic or asymptomtic w/ low LVEF or dilated ventricle

tricuspid stenosis is in who

men with rheumatic heart disease or carcinoid syndrome

pathophysio tricuspid stenosis

reduced CO causing r atrial p increase → systemic v congestion (hepatomegaly, ascites, edema)

symptoms tricuspid stenosis

left side rheumatic valve disease

abd pain from hepatomegaly, ascites, peripheral edema

signs tricuspid stenosis

prominent jugular v a-wave

rumbling mid-diastolic murmur (best heard at lower l sternal edge + exp), tricuspid opening snap

chest xray of tricuspid stenosis

prominent right atrial bulge

ecg tricuspid stenosis

peaked tall p waves in lead II

management tricuspid stenosis

diuretics + salt restriction

tricuspid valve replacement

tricuspid regurgitation - fxnal vs organic

functional - when r ventricle dilates (cor pulmonale, mi, pul htn)

organic - rheumatic heart disease, infective endocarditis, carcinoid syndrome

clinical features tricuspid regurgitation

symptoms of rhf - big jugular v cv wave, palpable liver

r ventricular impulse @ l sternal edge

blowing pansystolic murmur, heard best @ ins @ lower left sternal edge

afib

investigation for tricuspid regurgitation

echo - dilated r ventricle, thickening valve

management tricuspid regurgitation

severe - OP annuloplasty or annuloplication, rarely valve replacement

what is associated w/ fallot, noonan’s syndrome or congenital rubella syndrome?

pulmonary stenosis

symptoms pulmonary stenosis

asymptomatic or fatigue, syncope

symptoms of rhf

physical signs pulmonary stenosis

harsh midsystolic ejection murmur - heard on ins, left 2nd intercostal, w/ thrill

right ventricular 4th sound + prominent jugular v a-wave

r ventricular heave

investigation results pulmonary stenosis

xray - prominent pul a.

ecg - right heart hypertrophy

echo is investigation of choice

management pulmonary stenosis

pulmonary valvotomy

pulmonary regurgitation

from dilation of pul valve ring from pul htn or after fallot repair

decrescendo diastolic murmur